Diagnostic criteria for camptocormia in Parkinson's disease: A consensus-based proposal

Research Progress of Camptocormia in Parkinson Disease

Camptocormia, also known as bent spine syndrome, primarily affects individuals with Parkinson disease (PD). This review provides an overview of camptocormia in PD, covering its definition, epidemiology, causes, diagnosis, and treatment. In the epidemiology section, we delve into its prevalence, gender disparities, and ongoing genetic research. Regarding diagnosis and assessment, we discuss evolving diagnostic criteria and measurement techniques, as well as new diagnostic tools. For management and treatment, a wide array of options is available, from conservative methods such as physical therapy and botulinum toxin injections to surgical interventions such as spinal orthopedic surgery and deep brain stimulation. We stress the significance of personalized care and multidisciplinary collaboration. This comprehensive review aims to provide clinicians, researchers, and healthcare professionals with a comprehensive understanding of camptocormia in PD, highlighting its clinical features, diagnostic strategies, management approaches, and future perspectives.

An Exploratory Study on the Effects of Souchard Postural Gymnastics in Parkinson's Disease Patients with Camptocormia: A Quasi-Experimental Approach

Background/Objective: Parkinson's disease (PD), a prevalent neurodegenerative disorder, leads to motor and non-motor impairments, affecting quality of life. Camptocormia can be one of the motor signs of PD, characterized by a severe and abnormal forward flexion of the thoracolumbar spine that typically occurs when walking or standing. The following study aims to verify whether postural gymnastics can be an effective treatment for trunk control, balance, activities of daily living, and general well-being in patients with early-stage PD and camptocormia. Methods: Nine participants (mean age 67.7 ± 7.8) with early PD (Hoehn and Yahr Scale ≤ 2) received 10 biweekly physiotherapy sessions. Outcomes were measured using the Parkinson's Disease Questionnaire (PDQ-39) and Berg Balance Scale (BBS) along with trunk mobility and muscle tests according to the Medical Research Council (MRC) scale. Results: Statistically significant results were noted in the PDQ-39 mobility, ADLs and emotional well-being subscales and in the BBS; statistically significant improvements were also seen in trunk mobility and muscle strength. Conclusions: This study shows that the postural gymnastic treatment, according to Souchard, in patients with PD's camptocormia has obtained good results and has the potential timprove mobility and balance, encouraging and motivating patients in their rehabilitation journeys.

Camptocormia in Parkinson Disease: Systematic Review of Management Using Spine Surgery

OBJECTIVE

Postural abnormalities are a debilitating symptom of Parkinson disease (PD) that may require spinal intervention. Camptocormia is a unique abnormality most seen in PD, defined by a severe forward flexion of the trunk that completely resolves when supine. The condition presents a challenge due to an undefined pathophysiology and optimal therapeutic approach in a high-risk patient population. In this study, we systematically reviewed the literature regarding the use of spine surgery for the treatment of camptocormia in PD.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were systematically queried for studies involving spine surgery as treatment of PD-associated camptocormia. Studies involving nonsurgical management, involving deep brain stimulation, involving noncamptocormic PD patients undergoing surgery, or were out of scope were excluded.

RESULTS

The search resulted in 5 studies, with a total of 19 patients with PD with camptocormia who underwent spine surgery (73.7% women). The mean age was 69.5 years (range, 59-83), and the mean PD duration was 69.5 months (range, 36-84). Of 19 patients, 11 required surgical revision (57.9%), with an average of 0.68 revisions per patient (range, 0-2). Radiographic and patient-reported outcomes were inconsistently reported yet showed improvement. Ultimately, 18 patients were reported to have positive outcomes.

CONCLUSIONS

Despite an increased risk of complication and revision that is inherent to patients with PD, spine surgery has been proven as a reasonable alternative that should be prospectively studied further because 18 of 19 patients had favorable outcomes.

Botulinum Toxin for Axial Postural Abnormalities in Parkinson's Disease: A Systematic Review

Axial postural abnormalities (APAs), characterized by their frequency, disabling nature, and resistance to pharmacological treatments, significantly impact Parkinson's disease and atypical Parkinsonism patients. Despite advancements in diagnosing, assessing, and understanding their pathophysiology, managing these complications remains a significant challenge. Often underestimated by healthcare professionals, these disturbances can exacerbate disability. This systematic review assesses botulinum toxin treatments' effectiveness, alone and with rehabilitation, in addressing APAs in Parkinson's disease, utilizing MEDLINE (PubMed), Web of Science, and SCOPUS databases for source material. Of the 1087 records retrieved, 16 met the selection criteria. Most research has focused on botulinum toxin (BoNT) as the primary treatment for camptocormia and Pisa syndrome, utilizing mostly observational methods. Despite dose and injection site variations, a common strategy was using electromyography-guided injections, occasionally enhanced with ultrasound. Patients with Pisa syndrome notably saw consistent improvements in APAs and pain. However, studies on the combined effects of botulinum toxin and rehabilitation are limited, and antecollis is significantly under-researched. These findings recommend precise BoNT injections into hyperactive muscles in well-selected patients by skilled clinicians, avoiding compensatory muscles, and underscore the necessity of early rehabilitation. Rehabilitation is crucial in a multidisciplinary approach to managing APAs, highlighting the importance of a multidisciplinary team of experts.

Treatment of axial postural abnormalities in parkinsonism disorders: A systematic review of pharmacological, rehabilitative and surgical interventions

Axial postural abnormalities (PA) are frequent, highly disabling, and drug-refractory motor complications affecting patients with Parkinson's disease (PD) or atypical parkinsonism. Over the past few years, advances have been reached across diagnosis, assessment, and pathophysiological mechanisms of PA. Nonetheless, their management remains a challenge, and these disturbances are generally overlooked by healthcare professionals, potentially resulting in their worsening and impact on patients' disabilities. From shared consensus-based assessment and diagnostic criteria, PA calls for interdisciplinary management based on the complexity and multifactorial pathogenesis. In this context, we conducted a systematic literature review to analyze the available pharmacological and non-pharmacological treatment options for PA in PD according to the new expert-based classification of axial PA in Parkinsonism. Different multidisciplinary approaches, including dopaminergic therapy adjustment, physiotherapy, botulinum toxin injection, and deep brain stimulation, can improve PA depending on its type and severity. An early, interdisciplinary approach is recommended in PD patients to manage PA.

Dynamic evaluation of spine kinematics in individuals with Parkinson's disease and freezing of gait

BACKGROUND

Freezing of gait (FoG) is an episodic failure of gait exposing people with Parkinson's disease (PD) to a high risk of falling. Despite growing evidence of the interconnection between impaired trunk control and FoG, a detailed description of spinal kinematics during walking is still lacking in this population.

RESEARCH QUESTION

Do spinal alterations impact gait performance in individuals with PD and FoG?

METHODS

We analyzed kinematic data of 47 PD participants suffering (PD-FOG, N = 24) or not suffering from FoG (PD-NFOG, N = 23) and 15 healthy controls (HCO) during quiet standing and unperturbed walking. We estimated the main spinal variables (i.e., spinal length, lordosis and kyphosis angles, trunk inclination), the pelvis angles, and the shoulder-pelvis angles during gait and standing. We studied differences across conditions and groups and the relationships between postural and gait parameters using linear regression methods.

RESULTS

During standing and walking, both PD groups showed increased trunk inclination and decreased lordosis angle with respect to HCO, as well as a decreased range in variation of kyphosis angle, pelvic obliquity, and shoulder-pelvis angles. Only PD-FOG participants showed reduced range of lordosis angle and spinal length compared to HCO. PD-FOG individuals were also not able to straighten their spine during walking compared to standing. Stride length and velocity were decreased in both patient groups compared to HCO, while swing duration was reduced only in the PD-FOG group. In individuals with FoG, trunk inclination and lordosis angle showed moderate but significant positive correlations with all gait alterations.

SIGNIFICANCE

Spine alterations impacted gait performance in individuals with PD suffering from FoG. Excessive trunk inclination and poor mastering of the lordosis spinal region may create an unfavourable postural precondition for forward walking. Physical therapy should target combined spinal and stepping alterations in these individuals.

Inaugural dropped head syndrome and camptocormia in inflammatory myopathies: a retrospective study

OBJECTIVES

Inaugural axial muscle involvement, defined as dropped head syndrome (DHS) and/or camptocormia (CC), is poorly described in inflammatory myopathies (IM). This study aimed to further characterize IM patients with inaugural DHS/CC, their outcome and care management.

METHODS

This retrospective study included IM patients diagnosed between 2000 and 2021. The main inclusion criterion was IM revealed by axial muscle deficit (DHS/CC).

RESULTS

Twenty-seven patients were included; median (IQR) age at first symptoms was 66.0 years (55.5-75.0); 21 were female (77.8%). There were nine IBM, 33.3%, nine overlap myositis (OM, 33.3%), five DM, 18.5%, two immune checkpoint inhibitor-related myositis (7.4%), one focal myositis (3.7%) and one myositis with anti-Hu antibodies (3.7%). Age at first symptoms was ≤70 years in 16 patients (59.3%), including all DM patients and 8/9 OM patients (88.9%). In this group, partial remission of the disease was obtained in 9/16 (56.3%) and complete remission in 1/16 patients (6.3%); regression of DHS/CC was achieved in 3/16 patients (18.8%). Conversely, in the group of 11 patients aged >70 years at first symptoms, there were eight IBM (72.7%). Partial remission was obtained in 5/11 patients (45.5%), the disease was stable in 6/11 patients (54.5%); no complete remission was obtained nor regression of DHS/CC.

CONCLUSION

The analysis of IM patients with inaugural DHS/CC delineates two groups of patients according to the age at first symptoms in terms of clinical and outcome specificities, and proposes an adapted diagnostic and care management approach to prevent long-term complications.

Significant improvement after sensory tricks and trunk strength training for Parkinson's disease with antecollis and camptocormia: A case report

BACKGROUND

Patients with Parkinson's disease (PD) exhibit symptoms such as antecollis (AC) and camptocormia (CC). The pathology of these two conditions is unclear. Additionally, standard treatment methods have not been established. The article reports the case of a 65-year-old female patient with AC and CC who was treated with central and peripheral interventions to alleviate symptoms.

CASE SUMMARY

We present the case of a 65-year-old female PD patient with AC and CC. The course of the disease was 5 years. She was treated with rehabilitation strategies such as sensory tricks and trunk strength training. During the inpatient period, we compared and analyzed the patient's gait, rehabilitation assessment scale score, and angles of her abnormal trunk posture in the first week, the third week, and the fifth week. The patient's stride length increased, indicating that the patient's walking ability was improved. The Unified Parkinson's Disease Scale Part Three score and CC severity score decreased. Furthermore, the score of the other scale increased. In addition, the patient showed significant improvements in AC, upper CC, and lower CC angles.

CONCLUSION

This case study suggested that sensory tricks and trunk strength training are beneficial and safe for patients with AC and CC.

Postural deformities in Parkinson's disease: A bibliometric analysis based on web of science

Objective

Postural deformities are common debilitating conditions during the progression of Parkinson's disease (PD). However, the underlying pathophysiology and optimal treatment strategy are unclear. In this study, we aimed to identify primary research fields, important achievements and emerging trends in postural deformities in PD.

Methods

Web of Science Core Collection database was searched to retrieve all literature related to postural deformities in PD over the past 20 years. Data such as annual numbers of publications, countries of origin, publication journals, cooperation between countries, citation index and keywords were retrieved from the selected publications. Bibliometrix Package in R software were used for bibliometric analysis and visualization.

Results

In total, 211 publications that met the criteria were collected. Analyses had shown that the annual numbers of publications increased gradually with fluctuations. Japan was the most prolific country (n = 59). Italy participated in international cooperation the most frequently. Parkinsonism & related disorders (n = 25) took a prominent lead among all journals, and the most productive institution in this area was University of Verona (n = 27). The most local cited author was Tinazzi Michele. According to the thematic map, "scoliosis", "fusion", and "balance" have rapidly become research hot spots in related fields.

Conclusions

Articles pertaining to postural deformities in PD are still being published, in which the etiology is a combination of peripheral plus central involvement. Treatment approaches include rehabilitative exercises, oral medication, botulinum toxin injection, deep brain stimulation and spine surgery, which is getting current attention and would be a hot topic of future research.

Association of sagittal spinal alignment in the standing position with the masses and amounts of intramuscular non-contractile tissue of the trunk and lower extremity muscles in patients with Parkinson's disease

BACKGROUND

We examined the association of sagittal spinal alignment in the standing position with the masses and amounts of intramuscular non-contractile tissue of multiple trunk and lower extremity muscles, such as the hip joint muscles, measured using an ultrasound imaging device in patients with Parkinson's disease (PD).

METHODS

The participants were 10 patients with PD. Sagittal spinal alignment (thoracic kyphosis, lumbar lordosis, and sacral anterior inclination angles) in the standing position was measured using a Spinal Mouse. Muscle thicknesses and echo intensities of the trunk and lower extremity muscles, including the hip joint muscles, were also measured in the prone or supine position using an ultrasound imaging device.

FINDINGS

Partial correlation analysis with body height and weight as control variables showed that a low lumbar lordosis angle in the standing position was significantly associated with low thicknesses of the trunk extensor muscles (lumbar erector spinae and multifidus). Partial correlation analysis also revealed that a high sacral anterior inclination angle in the standing position was significantly associated with low lumbar multifidus muscle thickness. However, the thicknesses and echo intensities of the trunk flexor and hip joint muscles were not significantly related to thoracic kyphosis, lumbar lordosis, or sacral anterior inclination angles.

INTERPRETATION

The results of this study suggested the association between a low lumbar lordosis angle in the standing position and low lumbar erector spinae and multifidus muscle thicknesses and between a high sacral anterior inclination angle in the standing position and low lumbar multifidus muscle thickness in patients with PD.

Prevalence of axial postural abnormalities and their subtypes in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Axial postural abnormalities, mainly involving the spinal deformities, are disabling symptoms of Parkinson's disease (PD). However, the prevalence of axial postural abnormalities in PD and their clinical correlates remain unclear. The present study aimed to conduct a systematic review and meta-analysis of the prevalence of overall and subtypes of axial postural abnormalities in PD.

METHODS

PubMed, Embase, Web of Science and Cochrane databases were searched up to 31st March, 2022. We identified studies that reported the prevalence of axial postural abnormalities in PD. The pooled estimate of prevalence was calculated using a random effect model. Subgroup analysis and meta-regression were performed.

RESULTS

There were 19 studies met the inclusion criteria. The overall prevalence of axial postural abnormalities in PD was 22.1% (95% CI 19.7-24.5%). The prevalence of each subtype of axial postural abnormalities was 19.6% for scoliosis (95% CI 10.6-28.7%), 10.2% for camptocormia (95% CI 7.7-12.7%), 8% for Pisa syndrome (95% CI 4.7-11.4%), and 7.9% for antecollis (95% CI 3.9-11.9%). Subgroup analysis showed that the measuring method of axial postural abnormalities exerted significant effects on prevalence estimates. Axial postural abnormalities in PD were associated with older age, longer disease duration, higher H-Y stage, greater levodopa equivalent daily dose, more severe motor symptoms, motor fluctuations, and akinetic-rigid subtype.

CONCLUSIONS

Axial postural abnormalities, which include scoliosis, camptocormia, Pisa syndrome, and antecollis, are not uncommon in patients with PD. Future research on axial postural abnormalities should be based on uniform diagnostic criteria and measuring methods.

A summary index derived from Kinect to evaluate postural abnormalities severity in Parkinson’s Disease patients

Postural abnormalities are common disabling motor complications affecting patients with Parkinson’s disease (PD). We proposed a summary index for postural abnormalities (IPA) based on Kinect depth camera and explored the clinical value of this indicator. Seventy individuals with PD and thirty age-matched healthy controls (HCs) were enrolled. All participants were tested using a Kinect-based system with IPA automatically obtained by algorithms. Significant correlations were detected between IPA and the Movement Disorder Society-Sponsored Revision of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) total score (rs = 0.369, p = 0.002), MDS-UPDRS-III total score (rs = 0.431, p < 0.001), MDS-UPDRS-III 3.13 score (rs = 0.573, p < 0.001), MDS-UPDRS-III-bradykinesia score (rs = 0.311, p = 0.010), the 39-item Parkinson’s Disease Questionnaire (PDQ-39) (rs = 0.272, p = 0.0027) and the Berg Balance Scale (BBS) score (rs = −0.350, p = 0.006). The optimal cut-off value of IPA for distinguishing PD from HCs was 12.96 with a sensitivity of 97.14%, specificity of 100.00%, area under the curve (AUC) of 0.999 (0.997–1.002, p < 0.001), and adjusted AUC of 0.998 (0.993–1.000, p < 0.001). The optimal cut-off value of IPA for distinguishing between PD with and without postural abnormalities was 20.14 with a sensitivity, specificity, AUC and adjusted AUC of 77.78%, 73.53%, 0.817 (0.720–0.914, p < 0.001), and 0.783 (0.631–0.900, p < 0.001), respectively. IPA was significantly correlated to the clinical manifestations of PD patients, and could reflect the global severity of postural abnormalities in PD with important value in distinguishing PD from HCs and distinguishing PD with postural abnormalities from those without.

Postural abnormalities in Asian and Caucasian Parkinson's disease patients: A multicenter study

INTRODUCTION

Postural abnormalities (PA) are disabling features of Parkinson's disease (PD). Indirect analyses suggested a higher prevalence of PA among Asian patients compared to Caucasian ones, but no direct comparisons have been performed so far.

METHODS

An international, multicenter, cross-sectional study was performed in 6 European and Asian movement disorders centers with the aim to clarify differences and similarities of prevalence and characteristics of PA in Asian vs. Caucasian PD patients. Axial PA, encompassing antecollis (AC), camptocormia (CC), and Pisa syndrome (PS), and appendicular PA (appPA) were systematically searched and analysed in consecutive patients.

RESULTS

88 (27%) of 326 PD patients had PA (29.1% in Asians and 24.3% in Caucasians, p: 0.331). Prevalence of axial PA was 23.6% in Asians and 24.3% in Caucasians (p = 0.886), in spite of a longer disease duration among Caucasians, but a longer PA duration among Asians. No differences in prevalence between AC, CC, and PS were found between the two ethnicities. The prevalence of appPA was higher in Asians (p = 0.036), but the regression analysis did not confirm a significant difference related to ethnicity. Considering the whole population, male gender (OR, 4.036; 95% CI, 1.926-8.456; p < 0.005), a longer disease duration (OR, 2.61; 95% CI, 1.024-6.653; p = 0.044), and a higher axial score (OR, 1.242; 95% CI, 1.122-1.375; p < 0.0005) were the factors associated with axial PA.

CONCLUSION

The prevalence of axial PA in PD patients is not influenced by ethnicity. However, Asian PD patients tend to develop PA earlier in the disease course, particularly AC.

Automatic Measurement of Postural Abnormalities With a Pose Estimation Algorithm in Parkinson's Disease

Objective

This study aims to develop an automated and objective tool to evaluate postural abnormalities in Parkinson’s disease (PD) patients.

Methods

We applied a deep learning-based pose-estimation algorithm to lateral photos of prospectively enrolled PD patients (n = 28). We automatically measured the anterior flexion angle (AFA) and dropped head angle (DHA), which were validated with conventional manual labeling methods.

Results

The automatically measured DHA and AFA were in excellent agreement with manual labeling methods (intraclass correlation coefficient > 0.95) with mean bias equal to or less than 3 degrees.

Conclusion

The deep learning-based pose-estimation algorithm objectively measured postural abnormalities in PD patients.

Subthalamic Stimulation for Camptocormia in Parkinson's Disease: Association of Volume of Tissue Activated and Structural Connectivity with Clinical Effectiveness

BACKGROUND

Deep brain stimulation of the subthalamic nucleus (STN-DBS) has been reported to be effective for camptocormia in Parkinson's disease (PD). However, the association between clinical effectiveness and the stimulated volumes or structural connectivity remains unexplored.

OBJECTIVE

To investigate the effectiveness of STN-DBS for treating camptocormia in PD and its association with volumes of tissue activated (VTA) and structural connectivity.

METHODS

We reviewed video recordings of patients who had undergone STN-DBS. The total and upper camptocormia (TCC and UCC) angles were measured to quantify changes in camptocormia. The Movement Disorders Society Unified Parkinson's Disease Rating Scale III (MDS-UPDRS III) was used to assess motor symptoms. Pre- and postoperative brain images were collected for modeling volume of VTA and structural connectivity using Lead-DBS software.

RESULTS

Participants included 36 patients with PD (8 with TCC-camptocormia and 2 with UCC-camptocormia) treated with bilateral STN-DBS. After surgery, patients showed a significant improvement in postural alignment at follow-up (mean follow-up duration: 6.0±2.2 months). In the entire sample, higher structural connectivity to the right supplementary motor area (SMA) and right lateral premotor cortex along the dorsal plane (PMd) was associated with larger postsurgical improvements in axial signs and TCC angles after stimulation was turned on. In patients diagnosed with camptocormia, larger improvement in camptocormia angles after STN-DBS was associated with a larger VTA overlap with STN (R = 0.75, p = 0.032).

CONCLUSION

This study suggests that both VTA overlap with STN and structural connectivity to cortical motor regions are associated with the effectiveness of STN-DBS for managing camptocormia in PD.

Pallidal stimulation as treatment for camptocormia in Parkinson's disease

Camptocormia is a common and often debilitating postural deformity in Parkinson's disease (PD). Few treatments are currently effective. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) shows potential in treating camptocormia, but evidence remains limited to case reports. We herein investigate the effect of GPi-DBS for treating camptocormia in a retrospective PD cohort. Thirty-six consecutive PD patients who underwent GPi-DBS were reviewed. The total and upper camptocormia angles (TCC and UCC angles) derived from video recordings of patients who received GPi-DBS were used to compare camptocormia alterations. Correlation analysis was performed to identify factors associated with the postoperative improvements. DBS lead placement and the impact of stimulation were analyzed using Lead-DBS software. Eleven patients manifested pre-surgical camptocormia: seven had lower camptocormia (TCC angles ≥ 30°; TCC-camptocormia), three had upper camptocormia (UCC angles ≥ 45°; UCC-camptocormia), and one had both. Mean follow-up time was 7.3 ± 3.3 months. GPi-DBS improved TCC-camptocormia by 40.4% (angles from 39.1° ± 10.1° to 23.3° ± 8.1°, p = 0.017) and UCC-camptocormia by 22.8% (angles from 50.5° ± 2.6° to 39.0° ± 6.7°, p = 0.012). Improvement in TCC angle was positively associated with pre-surgical TCC angles, levodopa responsiveness of the TCC angle, and structural connectivity from volume of tissue activated to somatosensory cortex. Greater improvement in UCC angles was seen in patients with larger pre-surgical UCC angles. Our study demonstrates potential effectiveness of GPi-DBS for treating camptocormia in PD patients. Future controlled studies with larger numbers of patients with PD-related camptocormia should extend our findings.

Spinal Surgery for Parkinson Disease With Camptocormia: Propensity Score-Matched Cohort Study With Degenerative Sagittal Imbalance (DSI)

STUDY DESIGN

A propensity score-matched cohort study.

OBJECTIVE

The objective of this study was to compare the radiologic and clinical outcomes of camptocormia in Parkinson disease (PD) with degenerative sagittal imbalance (DSI) patients.

SUMMARY OF BACKGROUND DATA

Camptocormia in PD and DSI could be characterized by a dynamic deformity. However, no study has directly evaluated the outcomes of patients with camptocormia and DSI.

METHODS

Thirteen consecutive PD patients undergoing surgical correction for camptocormia were matched in a 1-to-2 format with 26 patients in the DSI group by propensity score-matching. Radiologic outcomes, including paravertebral muscle changes, and clinical outcomes were compared between the 2 groups. The rate of proximal junctional problems and reoperations were assessed.

RESULTS

PD patients with camptocormia had significantly greater preoperative coronal and sagittal malalignments (29.9 vs. 16.9 mm, P=0.019; 142.8 vs. 64.4 mm, P=0.0001, respectively) and weakness of paravertebral muscles compared with the DSI patients. Regarding the clinical outcomes, reoperations were significantly higher in the camptocormia group, compared with the DSI group (53.8% vs. 7.7%, P=0.001). Moreover, proximal junctional failure was developed in 8 patients in the camptocormia group, while 1 patient in the DSI group (61.5% vs. 3.8%, P=0.0001). In subgroup analysis, independent risk factors for the proximal junctional failure were the total fusion levels (hazard ratio=0.26, P=0.018) and the degree of fatty changes of the paravertebral muscles (hazard ratio=1.15, P=0.048).

CONCLUSIONS

PD patients undergoing spinal surgery for camptocormia had global malalignment and higher rates of complications compared with DSI patients. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

From the Gut to the Brain and Back: Therapeutic Approaches for the Treatment of Network Dysfunction in Parkinson's Disease

Parkinson's disease (PD) is a complex, multisystem, progressive, degenerative disorder characterized by severe, debilitating motor dysfunction, cognitive impairments, and mood disorders. Although preclinical research has traditionally focused on the motor deficits resulting from the loss of nigrostriatal dopaminergic neurons, up to two thirds of PD patients present separate and distinct behavioral changes. Loss of basal forebrain cholinergic neurons occurs as early as the loss of dopaminergic cells and contributes to the cognitive decline in PD. In addition, attentional deficits can limit posture control and movement efficacy caused by dopaminergic cell loss. Complicating the picture further is intracellular α-synuclein accumulation beginning in the enteric nervous system and diffusing to the substantia nigra through the dorsal motor neurons of the vagus nerve. It seems that α-synuclein's role is that of mediating dopamine synthesis, storage, and release, and its function has not been completely understood. Treating a complex, multistage network disorder, such as PD, likely requires a multipronged approach. Here, we describe a few approaches that could be used alone or perhaps in combination to achieve a greater mosaic of behavioral benefit. These include (1) using encapsulated, genetically modified cells as delivery vehicles for administering neuroprotective trophic factors, such as GDNF, in a direct and sustained means to the brain; (2) immunotherapeutic interventions, such as vaccination or the use of monoclonal antibodies against aggregated, pathological α-synuclein; (3) the continuous infusion of levodopa-carbidopa through an intestinal gel pad to attenuate the loss of dopaminergic function and manage the motor and non-motor complications in PD patients; and (4) specific rehabilitation treatment programs for drug-refractory motor complications.

Management of Pain in Parkinson's Disease

Pain is a very frequent symptom with influence on the quality of life in Parkinson’s disease (PD), but is still underdiagnosed and commonly treated only unsystematically. Pain etiology and pain character are often complex and multi-causal, and data regarding treatment recommendations are limited. Pain can be primarily related to PD but frequently it is associated with secondary diseases, such as arthrosis of the spine or joints. However, even basically PD-unrelated pain often is amplified by motor- or non-motor PD symptoms, such as akinesia or depression. Beyond an optimization of anti-parkinsonian treatment, additional pain treatment strategies are usually needed to properly address pain in PD. A careful pain history and diagnostic work-up is essential to rate the underlying pain pathophysiology and to develop a targeted therapeutic concept. This review gives an overview on how pain is treated in PD patients and how patients assess the effectiveness of these therapies; here, the manuscript focuses on pathophysiology-driven suggestions for a multimodal pain management in clinical practice.

Does the Degree of Trunk Bending Predict Patient Disability, Motor Impairment, Falls, and Back Pain in Parkinson's Disease?

Background: Postural abnormalities in Parkinson's disease (PD) form a spectrum of functional trunk misalignment, ranging from a "typical" parkinsonian stooped posture to progressively greater degrees of spine deviation. Objective: To analyze the association between degree of postural abnormalities and disability and to determine cut-off values of trunk bending associated with limitations in activities of daily living (ADLs), motor impairment, falls, and back pain. Methods: The study population was 283 PD patients with ≥5° of forward trunk bending (FTB), lateral trunk bending (LTB) or forward neck bending (FNB). The degrees were calculated using a wall goniometer (WG) and software-based measurements (SBM). Logistic regression models were used to identify the degree of bending associated with moderate/severe limitation in ADLs (Movement Disorders Society Unified PD Rating Scale [MDS-UPDRS] part II ≥17), moderate/severe motor impairment (MDS-UPDRS part III ≥33), history of falls (≥1), and moderate/severe back pain intensity (numeric rating scale ≥4). The optimal cut-off was identified using receiver operating characteristic (ROC) curves. Results: We found significant associations between modified Hoehn & Yahr stage, disease duration, sex, and limitation in ADLs, motor impairment, back pain intensity, and history of falls. Degree of trunk bending was associated only with motor impairment in LTB (odds ratio [OR] 1.12; 95% confidence interval [CI], 1.03-1.22). ROC curves showed that patients with LTB of 10.5° (SBM, AUC 0.626) may have moderate/severe motor impairment. Conclusions: The severity of trunk misalignment does not fully explain limitation in ADLs, motor impairment, falls, and back pain. Multiple factors possibly related to an aggressive PD phenotype may account for disability in PD patients with FTB, LTB, and FNB.

Quantitative assessment of posture in healthy controls and patients with Parkinson's disease

INTRODUCTION

A stooped posture is a main clinical feature of Parkinson's disease (PD). The assessment of posture is important to measure treatment effects. The aim of this study was to investigate the reliability of a standardized postural rating tool, to calculate minimal detectable change scores and to assess the role of gender and age.

METHODS

Two independent raters assessed total camptocormia (TCC), upper camptocormia (UCC) and Pisa angles of 192 PD patients and 78 healthy controls (HC) with the free NeuroPostureApp©(http://www.neuroimaging.uni-kiel.de/NeuroPostureApp). Reliabilities and linear models were calculated for different effects. Three subgroups were defined based on two thresholds (mean+2SD of HC and PD): A) normal, B) presumed stooped/lateral bended posture and C) postural disorder.

RESULTS

Intraclass correlation coefficients ranged between 0.71 and 0.95 for the interrater and test-retest reliability of the three angles. The minimal detectable change values in the PD patients were 3.7°, 6.7° and 2.1° for the TCC, UCC and Pisa angles, respectively. Men had a more stooped posture than women (p < 0.05). Patients with PD had a worse posture than HC (p < 0.001) in all three angles. For the TCC angle, 39.1% of the patients had a normal posture (<17.4°), 47.9% a presumed stooped posture (>17.4°, <30.2°) and 6.3° had camptocormia (>30.2°).

CONCLUSIONS

The NeuroPostureApp© is reliable. Our results confirmed gender differences and the progression of postural deviation in PD patients with age and empirically support the ≥30° TCC angle as a defining criterium for camptocormia. Diagnostic criteria for UCC and Pisa syndrome should be further explored in future studies.

Upper camptocormia in Parkinson's disease: Neurophysiological and imaging findings of both central and peripheral pathophysiological mechanisms

BACKGROUND

Camptocormia is a disabling complication of Parkinson's disease (PD), but its pathophysiology is poorly elucidated. Depending on the fulcrum of forward trunk flexion, two subtypes have been defined, upper (UCC) and lower camptocormia, the former being much more frequent. The aim of the study was to explore possible pathophysiological mechanisms of PD-related UCC.

METHODS

Ten PD patients with UCC (UCC-PD) and ten PD patients without camptocormia (NoUCC-PD) underwent simultaneous electromyography (EMG) of thoracic paraspinal (TPS), obliquus externus abdominis (OEA), rectus abdominis (RA), and iliopsoas (IP) muscles during relaxed standing (both groups) and trunk realignment (UCC-PD group). Quantitative EMG and magnetic resonance imaging (MRI) of TPS muscles were also performed.

RESULTS

UCC-PD patients showed hyperactivity of TPS and OEA muscles in quiet stance. During voluntary trunk extension, hyperactivity of OEA muscles persisted, thus revealing a co-contraction of flexor and extensor trunk muscles. Motor unit potentials (MUP) of TPS muscles showed shorter duration (p = 0.005) and lower amplitude (p = 0.004) in UCC-PD than in NoUCC-PD patients. MRI did not detect significant between-group differences in the cross-sectional area and fat fraction of TPS muscles, although the latter was higher in the UCC-PD than in the NoUCC-PD group at all thoracic levels.

CONCLUSION

Our findings suggest that hyperactivity of OEA might sustain UCC in PD. Concurrent mild myopathic changes in TPS muscles in PD with UCC may be secondary to muscle disuse but nevertheless may contribute to abnormal trunk posture.

The Effect of Medication and Deep Brain Stimulation on Posture in Parkinson's Disease

Introduction: Postural abnormalities are common in Parkinson's disease (PD) and increasing with disease progression. While many studies focus on balance and gait, postural alignment is only infrequently studied.

Purpose: The aim of the present study was to examine the immediate and long-term effects of medication and deep brain stimulation (DBS) in the subthalamic nucleus on postural alignment in PD.

Materials and Methods: PD patients (n = 192) in an advanced stage of disease were videotaped during a standardized l-dopa trial before and after DBS. The patients were tested with and without medication pre-surgical and retested post-surgical (6–24 months) in all treatment combinations of medication and DBS regarding the on and off conditions. The forward bending as total camptocormia (TCC) and upper camptocormia (UCC) angles and lateral bending as Pisa angle were assessed with the free downloadable NeuroPostureApp (http://www.neuroimaging.uni-kiel.de/NeuroPostureApp/). Three subgroups were defined according to normative values of healthy controls and according to clinical criteria: patients with normal posture, with stooped posture, and with postural disorders.

Results: A stooped posture was found in 82% of the patients with regard to the TCC angle and in 54% for the UCC angle. Sixty-two percent had an abnormal Pisa angle. Camptocormia was diagnosed in ~7% and a Pisa syndrome in 1% of the patients. Medication and DBS both significantly improved postural alignment in the entire cohort. Female and male patients benefit similarly by medication and stimulation. Subgroup analyses revealed that the effects were also significant for patients with stooped posture, and the effects were strongest for patients with camptocormia: they led to angles below the diagnostical criterion for camptocormia for 13 of 14 patients with TCC and 11 of 26 patients with UCC. DBS had an additional effect to medication over time for the Pisa angle.

Conclusion: Medication and DBS both improved postural alignment in PD patients, but effects were small for the entire cohort. Patients with camptocormia according to the TCC angle benefit strongest. The large differences of the treatment effects may indicate distinct pathological mechanisms for stooped posture and postural disorders. The TCC angle was shown to be sensitive to change. The UCC angle was less sensitive but may be a useful assessment tool for a subgroup.

Postural Abnormalities in Parkinson's Disease: An Epidemiological and Clinical Multicenter Study

INTRODUCTION

The overall frequency of postural abnormalities (PA) in Parkinson's disease (PD) is unknown. We evaluated the overall prevalence of PA and assessed the association with demographic and clinical variables.

METHODS

For this multicenter, cross-sectional study, consecutive PD outpatients attending 7 tertiary Italian centers were enrolled. Patients were evaluated and compared for the presence of isolated PA such as camptocormia, Pisa syndrome, and anterocollis and for combined forms (ie, camptocormia + Pisa syndrome) together with demographic and clinical variables.

RESULTS

Of the total 811 PD patients enrolled, 174 (21.5%; 95% confidence interval [CI], 18.6%-24.3%) presented PA, 144 of which had isolated PA and 30 had combined PA. The prevalence of camptocormia was 11.2% (95% CI, 9%-13.3%), Pisa syndrome 8% (95% CI, 6.2%-9.9%), and anterocollis 6.5% (95% CI, 4.9%-8.3%). Patients with PA were more often male and older with longer disease duration, more advanced disease stage, more severe PD symptoms, a bradykinetic/rigid phenotype, and poorer quality of life. They were initially treated with levodopa, and more likely to be treated with a combination of levodopa and dopamine agonist, took a higher daily levodopa equivalent daily dose, and had more comorbidities. Falls and back pain were more frequent in PD patients with PA than in those without PA. Multiple logistic regression models confirmed an association between PA and male gender, older age, Hoehn and Yahr stage, and total Unified Parkinson's Disease Rating Scale score.

CONCLUSIONS

PA are frequent and disabling complications in PD, especially in the advanced disease stages.

Do Upper and Lower Camptocormias Affect Gait and Postural Control in Patients with Parkinson's Disease? An Observational Cross-Sectional Study

Gait impairments and camptocormia (CC) are common and debilitating in patients with Parkinson's disease (PD). Two types of CC affect patients with PD, but no studies investigated their relative contribution in worsening gait and postural control. Therefore, we investigated spatiotemporal gait parameters, gait variability, and asymmetry and postural control in PD patients (Hoehn & Yahr ≤4) with upper CC and lower CC and patients without CC. This observational cross-sectional study involving patients with PD and upper CC (n=16) and lower CC (n=14) and without CC (n=16). The primary outcome measure was gait speed assessed by the GAITRite System. The secondary outcome measures were other spatiotemporal parameters, gait variability, and asymmetry. Postural control and balance were assessed with posturography and the Mini-BESTest. Patients with lower CC showed a higher H&Y stage (p=0.003), a worse PDQ8 (p=0.042), and a lower Mini-BESTest score (p=0.006) than patients with PD without CC. Patients with lower CC showed a reduced gait speed (p=0.012), stride length, and velocity than patients with PD without CC. Upper CC patients showed a higher stride length than lower CC ones (p=0.007). In the eyes open and closed condition, patients with lower CC showed a higher (worse) velocity of CoP displacement in mediolateral direction and length of CoP than patients with PD without CC. No significant between-group differences were measured in gait variability and asymmetry. In conclusion, lower CC was associated with more severe gait and postural control impairment than patients with upper CC and without CC. Categorizing CC based on the bending fulcrum is compulsory to identify patients with the worst performance and to implement specific rehabilitation programs.

Effect of subthalamic deep brain stimulation on posture in Parkinson's disease: A blind computerized analysis

INTRODUCTION

We sought to assess the effect of subthalamic deep brain stimulation (STN DBS) on Parkinson's disease (PD)-associated postural abnormalities.

METHODS

A computerized analysis of posture was used to quantify the thoracolumbar, thoracic, and cervical-occipital ventral angles, as well as the thoracolumbar and cervical-occipital lateral angles from the video-repository of three specialized movement disorder centers (n = 158 patients). Data was extracted from frames from video-recordings in the pre-surgical medication-ON (dopaminergic therapy) and post-surgical stimulation-ON/medication-ON states (STN DBS plus dopaminergic therapy). The sum of the five postural angles (global postural angle) was used to compare pre-vs. post-surgical trunk posture alterations. A multivariate analysis was used to examine the association between changes in the postural angles and demographic or clinical variables.

RESULTS

There was a 6.7% amelioration in the global postural angle between the pre- and post-surgical assessments (p = 0.031). Motor response to and pre-surgical dosage of levodopa, male gender, and shorter PD duration were identified as predictors for posture improvement after STN DBS. Cases meeting criteria for lower (n = 2) or upper (n = 1) camptocormia respectively improved by 48.1% in the ventral thoracolumbar angle (from 36.4 ± 0.0° to 18.9 ± 4.2°) and 13.8% in the ventral thoracic angle (from 49.1° to 42.3°). Cases meeting criteria for Pisa syndrome (n = 2) improved by 67.5% in the lateral thoracolumbar angle (from 16.9 ± 2.0° to 5.5 ± 4.7°).

CONCLUSIONS

STN DBS has a relatively small but significant effect on PD-associated postural abnormalities, potentially enhancing the effect of dopaminergic medications alone.

Gait festination in parkinsonism: introduction of two phenotypes

Gait festination is one of the most characteristic gait disturbances in patients with Parkinson’s disease or atypical parkinsonism. Although festination is common and disabling, it has received little attention in the literature, and different definitions exist. Here, we argue that there are actually two phenotypes of festination. The first phenotype entails a primary locomotion disturbance, due to the so-called sequence effect: a progressive shortening of step length, accompanied by a compensatory increase in cadence. This phenotype strongly relates to freezing of gait with alternating trembling of the leg. The second phenotype results from a postural control problem (forward leaning of the trunk) combined with a balance control deficit (inappropriately small balance-correcting steps). In this viewpoint, we elaborate on the possible pathophysiological substrate of these two phenotypes of festination and discuss their management in daily clinical practice.

Body height loss characterizes camptocormia in Parkinson's disease

Axial deformities such as camptocormia or Pisa syndrome in people with Parkinson's disease (PwP) are poorly understood. The scarcity of information may result from the shortage of reliable and responsive evaluation instruments. We evaluated the body height loss (BHL) as a new measure for PwP with axial deformities. 50 PwP with axial deformity defined by an UPDRS item 28 value of at least 2 were included in this mono-center study. We measured body height while lying supine and after 1 min of standing, providing a percentage value of BHL, and compared this measure to other clinical variables. BHL depended on the Hoehn and Yahr clinical stage and correlated with clinical scales for function and mobility, but not with timely measures of the axial disorder such as age at diagnosis or duration of disease. ANOVA showed that only lumbar flexion explained the variability of BHL (F = 21.0, p < 0.0001), but not kyphosis (F = 0.4, p = 0.74) or lateroflexion (F = 0.6, p = 0.6). Re-test reliability of BHL was good with к = 0.76 (p < 0.0001). BHL resulted from the lumbar spine and the hip joint and not from the thoracic spine or lateroflexion. This observation conforms to the concept of upper-type and lower-type camptocormia with only the latter leading to a BHL. The assessment of the BHL is shown to be a well defined, easy to perform, and reliable measure for the clinical evaluation of lower-type camptocormia.